A denial or cancellation will now be considered a violation under Delaware’s Unfair Trade Practices Act. The state approved legislation that added gender identity to Delaware’s anti-discrimination laws. The state could fine insurers up to $50,000 or take legal action if they fail to comply.

Walt Cherniak, spokesman for Aetna Inc., said that the company is in support of broadening coverage for transgender individuals.

Aetna’s individual and small-group plan filings for 2016 across the country, including Delaware, already eliminated any previously existing exclusions from coverage for treatment relating to gender reassignment, he added.

Highmark Delaware received the bulletin Wednesday, Matt Stehl, a spokesman for the insurer said, and is beginning to review the document.

At this point, it is too early to determine the bulletin’s impact, he said.

Under the state’s anti-discrimination act, “gender identity” means “a gender-related identity, appearance, expression or behavior of a person, regardless of the person’s assigned sex at birth.”

Sarah McBride, a transgender woman on the board of Equality Delaware, a lesbian, gay, bisexual and transgender advocacy organization, said that the bulletin continues the state’s role as a national leader on transgender equality.

“Transgender people deserve access to medically necessary health care just like everyone else, ” said McBride, who testified in Legislative Hall when the anti-discrimination bill was introduced.

However, even in states with those laws in place, equal access to health care is not guaranteed for transgender people, said Lisa Goodman, president of Equality Delaware.

Though creating the bulletin was a complicated process, Goodman said that it makes Delaware an even more attractive state to live and work.

“This continues to send the message that Delaware treats all of its citizens fairly and welcomes everyone,” she said.

There are no concrete numbers on how many transgender Delawareans have experienced health insurance exclusions, but she said the bulletin makes it very clear that now everyone should have access to care. About 2,800 transgender men and women live in Delaware.

Delaware’s move is in step with a nationwide trend as more than a third of Fortune 500 companies now offer transgender-inclusive health benefits, data from the Human Rights Coalition shows.

The insurance guidance also states that services will not be denied for a transgender person if the care has been deemed medically necessary by a doctor and similar procedures would be covered for a non-transgender individual.

It does not impact state Medicaid or Medicare plans, but does apply to all Obamacare plans offered on Delaware’s online health insurance marketplace. President Barack Obama’s health care law also has a nondiscrimination mandate.

The state policy will be effective immediately and in place “unless withdrawn or superseded by subsequent law, regulation or bulletin.” New insurance policies will be “disapproved” by the state Insurance Department if health coverage for transgender people is excluded or limited. Questions and comments can be emailed to DOI_LandH@state.de.us.

An increasing number of large employers are voluntarily covering transgender treatment, following medical recognition that it can lead to healthier outcomes overall for the individuals involved. The number was up to 418 last year, from none in 2002, according to the U.S. Health and Human Services Department.

The Delaware move comes three years after the Gender Identity Nondiscrimination Act was signed into law. The bill gives transgender Delawareans equal rights and forbids discrimination against a person on the basis of gender identity.